| Coverage Description | Horizon HMO Coinsurance |
| Primary Care Physician Copayment | $40 |
| Specialist Copayment | Subject to deductible and coinsurance. |
| Deductible | $2,500 Individual / $5,000 Family Deductible (Aggregate) |
| Coinsurance | 50% Coinsurance |
| Maximum Out of Pocket | $5,000 Individual / $10,000 Family |
| Lifetime Benefit Maximum | Unlimited |
Inpatient Hospital
(Subject to preapproval) | Subject to deductible and coinsurance. |
| Ambulatory Surgical Center Facility Charges | Subject to deductible and coinsurance. |
| Hospital Outpatient Facility Charges | Subject to deductible and coinsurance. |
| Emergency Room Copayment | $100 (Credited toward inpatient admission if admitted within 24 hours). Emergency room copayment is payable in addition to applicable copayment, deductible and coinsurance. |
Biologically Based Mental Illness and Alcoholism
(Inpatient is subject to preapproval) | Subject to deductible and coinsurance. |
| Non-Biologically Based Mental Illness and Substance Abuse | Maximum of 30 days inpatient care per calendar year.One inpatient day may be exchanged for 2 outpatient visits; maximum 20 visits per calendar year. |
| Blood/Blood Products/Processing | Subject to deductible and coinsurance.. |
| Diagnostic X-ray/Lab | Subject to deductible and coinsurance. |
Durable Medical Equipment
(Subject to preapproval) | Subject to deductible and coinsurance. |
Home Health Care and Hospice Care
(Subject to preapproval) | Unlimited days; subject to deductible and coinsurance. |
| Maternity | $25 copayment for the initial visit;
$0 copayment thereafter. |
| Prescription Drugs | Subject to deductible and coinsurance. Coinsurance paid for covered prescription drugs does not count toward the maximum out of pocket. |
| Preventive Care | Office visit copayment per visit. |
Rehabilitation Centers
(Subject to preapproval) | Subject to deductible and coinsurance. |
| Speech, Physical (Subject to preapproval), Occupational and Cognitive Rehabilitation Therapies | Subject to deductible and coinsurance.Limited to 30 visits per calendar year. |
| Therapeutic Manipulations | Subject to deductible and coinsurance. Limited to 30 visits per calendar year and 2 modalities per visit. |
